Gynaecology Flashcards

Question

Indications for pipelle endometrial biopsy in a patient presenting with HMB?

Answer 1

Persistent IMB, >45 years old, and/or failure of pharmacological treament

Answer 2

Suspected submucosal fibroids Suspected endometrial pathology, such as endometrial hyperplasia or cancer Persistent intermenstrual bleeding

Answer 3

Possible large fibroids (palpable pelvic mass) Possible adenomyosis (associated pelvic pain or tenderness on examination) Examination is difficult to interpret (e.g. obesity) Hysteroscopy is declined

Answer 4

Management of identifiable cause Symptomatic relief (non contraceptive): tranexamic acid or mefenamic acid Contraception: Minera coil (1st line), COCP, cyclical oral progestogens, progesterone only contraception (depo, implant POP) NB: oral norethisterone (Taken day 5-26 of cycle) does not work as a contraceptive when taken in this manner

Answer 5

Endometrial ablation Hysterectomy (subtotal or total, ovaries not removed unless abnormal. Can be performed through abdominal incision or through the vagina Fibroids: myomectomy and uterine artery embolism

Answer 6

Referral to secondary care for further investigation and management is indicated if treatment is unsuccessful, symptoms are severe or there are large fibroids (more than 3 cm).

Answer 7

First line contraceptive option Also acts as a contraceptive. Is licensed for 5 years treatment. Thins endometrium and can shrink fibroids.

Answer 8

(Taken day 5-26 of cycle)

Answer 9

No effect on fertility Non-hormonal Mefenamic acid also analgesic

Answer 10

A hysterectomy is the surgical removal of the uterus. It is a very common procedure, performed for a variety of indications. It can be classified by the amount of tissue resected Total hysterectomy Sub-total hysterectomy Total hysterectomy and bilateral salpingo-oophorectomy Radical hysterectomy There are three main approaches to a hysterectomy. The principles and steps for each approach are the same (but in a different order). Abdominal – via an incision in the abdomen. Vaginal – via incision through the superior part of the vagina. Laparoscopic – via small incisions in the abdomen, and using laparoscopes and a uterine manipulator.

Answer 11

removal of the uterus and cervix

Answer 12

removal of the body of the uterus only (leaving the cervix behind)

Answer 13

removal of the uterus, cervix, fallopian tubes and ovaries.

Answer 14

Removal of: Uterus Cervix Parametrium Vaginal cuff Part of or entire fallopian tubes Ovaries may be removed or left behind (depending on the patients age)

Answer 15

Mobilisation should be encouraged as soon as possible. Discharge is usually after 1-2 days for vaginal and laparoscopic hysterectomy, and 2-5 days for abdominal hysterectomy (depending on the type of incision – generally longer stay if midline incision).

Answer 16

Depends on uterus size and indication Low transverse incision Midline incision (may be necessitated in a large fibroid uterus for example)

Answer 17

Abdominal and laproscopic hysterectomy are perfomed under general anestethic Vaginal hysterectomy may be performed under regional anaesthesia (spinal/ epidural). A general anaesthetic is not required.

Answer 18

Heavy menstrual bleeding Pelvic pain Uterine prolapse (vaginal hysterectomy ) Gynaecological malignancy (usually ovarian, uterine or cervical) Risk reducing surgery, usually in cases of BRCA 1 or 2 mutations, or Lynch syndrome. Hysterectomy may also be performed as a life saving procedure in the management of major postpartum haemorrhage.

Answer 19

Damage to bladder and/or uterter and/or long term distrbance to bladder function Damage to the bowel Hemorrhage requiring blood tranfusion (relatively common) Return to theatre: bleeding/wound dehissince Pelvic abscess/infection VTE or PE Risk of death within 6 weeks, 32 women in every 100 000 (rare). The main causes of death are pulmonary embolism and cardiac disease. If the ovaries are conserved, menopause may occur earlier (by 1-2 years) due to a change in the blood supply to the ovaries.

Answer 20

Dysmenorrhoea or “painful periods” is the most common of all gynaecological symptoms. It is generally described as a crampy lower abdominal pain, which starts at the onset of menstruation. It can be classified as either: Primary – menstrual pain occurring with no underlying pelvic pathology. Secondary – menstrual pain that occurs with an associated pelvic pathology.

Answer 21

In the absence of fertilisation of the egg, the corpus luteum regresses, and there is a subsequent decline in oestrogen and progesterone production. The endometrial cells are sensitive to this decline in progesterone, and respond with prostaglandin release. Prostaglandins have two main actions in the uterus: Spiral artery vasospasm – leading to ischaemic necrosis and shedding of the superficial layer of the endometrium. Increased myometrial contractions. Primary dysmenorrhoea is thought to occur secondary to the excessive release of prostaglandins (PGF2α and PGE2) by endometrial cells.

Answer 22

Early menarche Long menstrual phase Heavy periods Smoking Nuliparity

Answer 23

The typical description of dysmenorrhoea is lower abdominal or pelvic pain, which can radiate to lower back or anterior thigh. Pain is crampy in nature. It usually lasts for 48-72 hours around the menstrual period, and is characteristically worst at the onset of menses. The pain can be associated with other symptoms, such as; malaise, nausea, vomiting, diarrhoea, dizziness. Abdominal and pelvic examinations (including speculum examination of cervix) are performed but are usually unremarkable. Uterine tenderness may be present. Note: Dysmenorrhoea may resolve following pregnancy.

Answer 24

Endometriosis Adenomyosis Pelvic inflammatory disease Adhesions

Answer 25

No investigations are specific to primary dysmenorrhoea and therefore the work up is focused on ruling out underlying pathology. If the patient is at high risk of a sexually transmitted infection, then a high vaginal swab and endocervical swabs are indicated to screen for underlying infection. If on examination a pelvic mass is palpated, a transvaginal ultrasound scan (TVS) should be performed to investigate further.

Answer 26

Lifestyle Changes: Stop smoking (there is a clear relationship between smoking and dysmenorrhoea). Pharmacological: Anagelsia (First line): NSAIDs (ibuprofen, naproxen, mefenamic acid). They work by inhibiting the production of prostaglandins; which have been implicated in the pathogenesis of primary dysmenorrhoea. And/or paracetamol 3-6 month trial of hormonal contraception (Second line): Monophasic combined oral contraceptive pill is most commonly used first line. Intrauterine system (e.g Mirena coil) may also be effective. Non-Pharmacological Local application of heat (water bottles or heat patch) Transcutaneous Electrical Nerve Stimulation (TENS)

Answer 27

Amenorrhoea refers to a lack of menstrual periods. Primary amenorrhoea is when the patient has never developed periods. Secondary amenorrhoea is when the patient previously had periods that subsequently stopped.

Answer 28

Abnormal uterine bleeding refers to irregularities in the menstrual cycle, affecting frequency, duration, regularity of the cycle length and the volume of menses. Irregular menstrual periods indicate anovulation (a lack of ovulation) or irregular ovulation. This occurs due to disruption of the normal hormonal levels in the menstrual cycle, or ovarian pathology. It can be due to: Extremes of reproductive age (early periods or perimenopause) Polycystic ovarian syndrome Physiological stress (excessive exercise, low body weight, chronic disease and psychosocial factors) Medications, particularly progesterone only contraception, antidepressants and antipsychotics Hormonal imbalances, such as thyroid abnormalities, Cushing’s syndrome and high prolactin

Answer 29

Intermenstrual bleeding (IMB) refers to any bleeding that occurs between menstrual periods. This is a red flag that should make you consider cervical and other cancers, although other causes are more common.

Answer 30

Hormonal contraception Cervical ectropion, polyps or cancer Sexually transmitted infection Endometrial polyps or cancer Vaginal pathology, including cancers Pregnancy Ovulation can cause spotting in some women Medications, such as SSRIs and anticoagulants

Answer 31

Dysmenorrhoea describes painful periods. The causes are: Primary dysmenorrhoea (no underlying pathology) Endometriosis or adenomyosis Fibroids Pelvic inflammatory disease Copper coil Cervical or ovarian cancer

Answer 32

Menorrhagia refers to heavy menstrual bleeding. This can be caused by: Dysfunctional uterine bleeding (no identifiable cause) Extremes of reproductive age Fibroids Endometriosis and adenomyosis Pelvic inflammatory disease (infection) Contraceptives, particularly the copper coil Anticoagulant medications Bleeding disorders (e.g. Von Willebrand disease) Endocrine disorders (diabetes and hypothyroidism) Connective tissue disorders Endometrial hyperplasia or cance Polycystic ovarian syndrome

Answer 33

Postcoital bleeding (PCB) refers to bleeding after sexual intercourse. This is a red flag that should make you consider cervical and other cancers, although other causes are more common. Often no cause is found. The key causes are: Cervical cancer, ectropion or infection Trauma Atrophic vaginitis Polyps Endometrial cancer Vaginal cancer

Answer 34

Urinary tract infection Dysmenorrhoea (painful periods) Irritable bowel syndrome (IBS) Ovarian cysts Endometriosis Pelvic inflammatory disease (infection) Ectopic pregnancy Appendicitis Mittelschmerz (cyclical pain during ovulation) Pelvic adhesions Ovarian torsion Inflammatory bowel disease (IBD)

Answer 35

Bacterial vaginosis Candidiasis (thrush) Chlamydia Gonorrhoea Trichomonas vaginalis Foreign body Cervical ectropion Polyps Malignancy Pregnancy Ovulation (cyclical) Hormonal contraception

Answer 36

Pruritus vulvae refers to itching of the vulva and vagina Irritants such as soaps, detergents and barrier contraception Atrophic vaginitis Infections such as candidiasis (thrush) and pubic lice Skin conditions such as eczema Vulval malignancy Pregnancy-related vaginal discharge Urinary or faecal incontinence Stress

Answer 37

Primary amenorrhoea is defined as not starting menstruation: By 13 years when there is no other evidence of pubertal development By 15 years of age where there are other signs of puberty, such as breast bud development

Answer 38

Hypogonadism refers to a lack of the sex hormones, oestrogen and testosterone, that normally rise before and during puberty. A lack of these hormones causes a delay in puberty. The lack of sex hormones is fundamentally due to one of two reasons: Hypogonadotropic hypogonadism: a deficiency of LH and FSH Hypergonadotropic hypogonadism: a lack of response to LH and FSH by the gonads (the testes and ovaries)

Answer 39

Hypogonadotropic hypogonadism involves deficiency of LH and FSH, leading to deficiency of the sex hormones (oestrogen). LH and FSH are gonadotrophins produced by the anterior pituitary gland in response to gonadotropin releasing hormone (GnRH) from the hypothalamus. Since no gonadotrophins are simulating the ovaries, they do not respond by producing sex hormones (oestrogen). Therefore, “hypogonadotropism” causes “hypogonadism”. A deficiency of LH and FSH is the result of abnormal functioning of the hypothalamus or pituitary gland. This could be due to: Hypopituitarism (under production of pituitary hormones) Damage to the hypothalamus or pituitary, for example, by radiotherapy or surgery for cancer Significant chronic conditions can temporarily delay puberty (e.g. cystic fibrosis or inflammatory bowel disease) Excessive exercise or dieting can delay the onset of menstruation in girls Constitutional delay in growth and development is a temporary delay in growth and puberty without underlying physical pathology Endocrine disorders such as growth hormone deficiency, hypothyroidism, Cushing’s or hyperprolactinaemia Kallman syndrome

Answer 40

Hypergonadotropic hypogonadism is where the gonads fail to respond to stimulation from the gonadotrophins (LH and FSH). Without negative feedback from the sex hormones (oestrogen), the anterior pituitary produces increasing amounts of LH and FSH. Consequently, you get high gonadotrophins (“hypergonadotropic”) and low sex hormones (“hypogonadism”). Hypergonadotropic hypogonadism is the result of abnormal functioning of the gonads. This could be due to: Previous damage to the gonads (e.g. torsion, cancer or infections such as mumps) Congenital absence of the ovaries Turner’s syndrome (XO)

Answer 41

Kallman syndrome is a genetic condition causing hypogonadotrophic hypogonadism, with failure to start puberty. It is associated with a reduced or absent sense of smell (anosmia).

Answer 42

Congenital adrenal hyperplasia is caused by a congenital deficiency of the 21-hydroxylase enzyme. This causes underproduction of cortisol and aldosterone, and overproduction of androgens from birth. It is a genetic condition inherited in an autosomal recessive pattern. In a small number of cases, it involves a deficiency of 11-beta-hydroxylase rather than 21-hydroxylase. In severe cases, the neonate is unwell shortly after birth, with electrolyte disturbances and hypoglycaemia. In mild cases, female patients can present later in childhood or at puberty with typical features: Tall for their age Facial hair Absent periods (primary amenorrhoea) Deep voice Early puberty

Answer 43

Androgen insensitivity syndrome is a condition where the tissues are unable to respond to androgen hormones (e.g. testosterone), so typical male sexual characteristics do not develop. It results in a female phenotype, other than the internal pelvic organs. Patients have normal female external genitalia and breast tissue. Internally there are testes in the abdomen or inguinal canal, and an absent uterus, upper vagina, fallopian tubes and ovaries.

Answer 44

Structural pathology in the pelvic organs can prevent menstruation. If the ovaries are unaffected, there will be typical secondary sexual characteristics, but no menstrual periods. There may be cyclical abdominal pain as menses build up but are unable to escape through the vagina. Structural pathology that can cause primary amenorrhoea include: Imperforate hymen Transverse vaginal septae Vaginal agenesis Absent uterus Female genital mutilation

Answer 45

The threshold for initiating investigations is no evidence of pubertal changes in a girl aged 13. Investigation can also be considered when there is some evidence of puberty but no progression after two years.

Answer 46

BLOODS FOR UNDERLYING MEDICAL CONDITIONS Full blood count and ferritin for anaemia U&E for chronic kidney disease Anti-TTG or anti-EMA antibodies for coeliac disease BLOODS FOR HORMONAL ABNORMALITIES FSH and LH (will be low in hypogonadotropic hypogonadism and high in hypergonadotropic hypogonadism) Thyroid function tests Insulin-like growth factor I is used as a screening test for GH deficiency Prolactin (raised in hyperprolactinaemia) Testosterone is raised in polycystic ovarian syndrome, androgen insensitivity syndrome and congenital adrenal hyperplasia Genetic testing with a microarray test to assess for underlying genetic conditions: Turner’s syndrome (XO) IMAGING Xray of the wrist to assess bone age and inform a diagnosis of constitutional delay Pelvic ultrasound to assess the ovaries and other pelvic organs MRI of the brain to look for pituitary pathology and assess the olfactory bulbs in possible Kallman syndrome

Answer 47

Management of primary amenorrhoea involves establishing and treating the underlying cause. Where necessary, replacement hormones can induce menstruation and improve symptoms. Patients with constitutional delay in growth and development may only require reassurance and observation. Where the cause is due to stress or low body weight secondary to diet and exercise, treatment involves a reduction in stress, cognitive behavioural therapy and healthy weight gain. Where the cause is due to an underlying chronic or endocrine condition, management involves optimising treatment for that condition. In patients with hypogonadotrophic hypogonadism, such as hypopituitarism or Kallman syndrome, treatment with pulsatile GnRH can be used to induce ovulation and menstruation. This has the potential to induce fertility. Alternatively, where pregnancy is not wanted, replacement sex hormones in the form of the combined contraceptive pill may be used to induce regular menstruation and prevent the symptoms of oestrogen deficiency. In patients with an ovarian cause of amenorrhoea, such as polycystic ovarian syndrome, damage to the ovaries or absence of the ovaries, the combined contraceptive pill may be used to induce regular menstruation and prevent the symptoms of oestrogen deficiency.

Answer 48

Constitutional delay in puberty Chromosomal or genetic abnormalities such as Turner syndrome (45 XO) (gonadal dysgenisis) Kallmann syndrome and androgen insensitivity syndrome. Disruption of the functioning of the hypothalamic or pituitary glands (functional hypothalamic amenorrhoea) For example as a result of: - Anorexia and other eating disorders, - Excessive exercise - Extreme physical or psychological stress Structural abnormalities of the genital tract such as: - Imperforate hymen obstructing menstrual flow (leading to haematocolpos) - Uterine agenesis - Pregnancy

Answer 49

Secondary amenorrhea is defined as no menstruation for more than three months after previous regular menstrual periods. Consider assessment and investigation after three to six months. In women with previously infrequent irregular periods, consider investigating after six to twelve months.

Answer 50

Pregnancy is the most common cause Menopause and premature ovarian failure Hormonal contraception (e.g. IUS or POP) Hypothalamic or pituitary pathology (hypothalamic amenorrhoea - (e.g. secondary stress, excessive exercise)), Ovarian causes such as polycystic ovarian syndrome (androgen levels raised) Uterine pathology such as Asherman’s syndrome (intrauterine adhesions) Thyroid pathology (thyrotoxicosis, hypothyroidism) Hyperprolactinaemia Sheenans syndrome

Answer 51

The hypothalamus reduces the production of GnRH in response to significant physiological or psychological stress. This leads to hypogonadotropic hypogonadism and amenorrhoea. The hypothalamus responds this way to prevent pregnancy in situations where the body may not be fit for it, for example: Excessive exercise (e.g. athletes) Low body weight and eating disorders Chronic disease Psychological stress

Answer 52

Pituitary causes of secondary amenorrhoea include: Pituitary tumours, such as a prolactin-secreting prolactinoma Pituitary failure due to trauma, radiotherapy, surgery or Sheehan syndrome

Answer 53

High prolactin levels act on the hypothalamus to prevent the release of GnRH. Without GnRH, there is no release of LH and FSH. This causes hypogonadotropic hypogonadism. Only 30% of women with a high prolactin level will have galactorrhea (breast milk production and secretion). The most common cause of hyperprolactinaemia is a pituitary adenoma secreting prolactin. Where there are high prolactin levels, a CT or MRI scan of the brain is used to assess for a pituitary tumour. Often there is a microadenoma that will not appear on the initial scan, and follow up scans are required to identify tumours that may develop later. Often no treatment is required for hyperprolactinaemia. Dopamine agonists such as bromocriptine or cabergoline can be used to reduce prolactin production These medications treat hyperprolactinaemia, Parkinson’s disease and acromegaly.

Answer 54

Detailed history and examination to assess for potential causes Ultrasound of the pelvis to diagnose polycystic ovarian syndrome Hormonal blood tests: - Beta human chorionic gonadotropin (HCG) urine or blood tests (pregnancy) -LH and FSH - Prolactin (can be measured to assess for hyperprolactinaemia, followed by an MRI to identify a pituitary tumour) - Thyroid stimulating hormone (TSH) (screen for thyroid pathology) This is followed by T3 and T4 when the TSH is abnormal) - Testosterone: (Raise testosterone indicates polycystic ovarian syndrome, androgen insensitivity syndrome or congenital adrenal hyperplasia)

Answer 55

High FSH suggests primary ovarian failure High LH, or LH:FSH ratio, suggests polycystic ovarian syndrome

Answer 56

Require a withdrawal bleed every 3 – 4 months to reduce the risk of endometrial hyperplasia and endometrial cancer. Medroxyprogesterone for 14 days, or regular use of the combined oral contraceptive pill, can be used to stimulate a withdrawal bleed.

Answer 57

Management of secondary amenorrhoea involves establishing and treating the underlying cause. Where necessary, replacement hormones can induce menstruation and improve symptoms.

Answer 58

Patients with amenorrhoea associated with low oestrogen levels are at risk increased risk of osteoporosis. Where the amenorrhoea lasts more than 12 months, treatment is indicated to reduce the risk of osteoporosis: Ensure adequate vitamin D and calcium intake Hormone replacement therapy or the combined oral contraceptive pill

Answer 59

Premenstrual syndrome (PMS) describes the psychological, emotional and physical symptoms that occur during the luteal phase of the menstrual cycle, particularly in the days prior to the onset of menstruation. These symptoms can be distressing and significantly impact quality of life. Most women will experience some of the symptoms of premenstrual syndrome. The critical aspects are the severity of the symptoms, and the impact these symptoms have on the woman’s functioning and quality of life. The symptoms of PMS resolve once menstruation begins. Symptoms are not present before menarche, during pregnancy or after menopause. These are key things to note when you take a history. Premenstrual syndrome is though to the caused by fluctuation in oestrogen and progesterone hormones during the menstrual cycle. The exact mechanism is not known, but it may be due to increased sensitivity to progesterone or an interaction between the sex hormones and the neurotransmitters serotonin and GABA.

Answer 60

There is a long list of symptoms that can occur with premenstrual syndrome, and these will vary with the individual. Common symptoms include: Low mood Anxiety Mood swings Irritability Bloating Fatigue Headaches Breast pain Reduced confidence Cognitive impairment Clumsiness Reduced libido These symptoms can occur in the absence of menstruation after a hysterectomy, endometrial ablation or on the Mirena coil, as the ovaries continue to function and the hormonal cycle continues. They can also occur in response to the combined contraceptive pill or cyclical hormone replacement therapy containing progesterone, and this is described as progesterone-induced premenstrual disorder. When features are severe and have a significant effect on quality of life, this is called premenstrual dysphoric disorder.

Answer 61

Diagnosis is made based on a symptom diary spanning two menstrual cycles. The symptom diary should demonstrate cyclical symptoms that occur just before, and resolve after, the onset of menstruation. A definitive diagnosis may be made, under the care of a specialist, by administering a GnRH analogues to halt the menstrual cycle and temporarily induce menopause, to see if the symptoms resolve. The following management options can be initiated in primary care: General healthy lifestyle changes, such as improving diet, exercise, alcohol, smoking, stress and sleep Combined contraceptive pill (COCP) SSRI antidepressants Cognitive behavioural therapy (CBT) RCOG recommends COCPs containing drospirenone first line (i.e. Yasmin). Drospironone as some antimineralocortioid effects, similar to spironolactone. Continuous use of the pill, as opposed to cyclical use, may be more effective. Severe cases should be managed by a multidisciplinary team, involving GPs, gynaecologists, psychologists and dieticians. Continuous transdermal oestrogen (patches) can be used to improve symptoms. Progestogens are required for endometrial protection against endometrial hyperplasia when using oestrogen. This can be in the form of low dose cyclical progestogens (e.g. norethisterone) to trigger a withdrawal bleed, or the Mirena coil. GnRH analogues can be used to induce a menopausal state. They are very effective at controlling symptoms; however, they are reserved for severe cases due to the adverse effects (e.g. osteoporosis). Hormone replacement therapy can be used to add back the hormones to mitigate these effects. Hysterectomy and bilateral oophorectomy can be used to induce menopause where symptoms are severe and medical management has failed. Hormone replacement therapy will be required, particularly in women under 45 years. Danazole and tamoxifen are options for cyclical breast pain, initiated and monitored by a breast specialist. Spironolactone may be used to treat the physical symptoms of PMS, such as breast swelling, water retention and bloating.

Answer 62

Intramural: within the myometrium (the muscle of the uterus). As they grow, they change the shape and distort the uterus. Subserosal means (just below the outer layer of the uterus) These fibroids grow outwards and can become very large, filling the abdominal cavity. Submucosal (just below endometirum) Pedunculated (on a stalk)

Answer 63

Fibroids are often asymptomatic. They can present in several ways: Heavy menstrual bleeding (menorrhagia) is the most frequent presenting symptom Prolonged menstruation, lasting more than 7 days Abdominal pain, worse during menstruation Bloating or feeling full in the abdomen Urinary or bowel symptoms due to pelvic pressure or fullness Deep dyspareunia (pain during intercourse) Reduced fertility Abdominal and bimanual examination may reveal a palpable pelvic mass or an enlarged firm non-tender uterus.

Answer 64

Hysteroscopy is the initial investigation for submucosal fibroids presenting with heavy menstrual bleeding. Pelvic ultrasound is the investigation of choice for larger fibroids. MRI scanning may be considered before surgical options, where more information is needed about the size, shape and blood supply of the fibroids.

Answer 65

For fibroids less than 3 cm, the medical management is the same as with heavy menstrual bleeding: Mirena coil (1st line) – fibroids must be less than 3cm with no distortion of the uterus Symptomatic management with NSAIDs and tranexamic acid Combined oral contraceptive Cyclical oral progestogens Surgical options for managing smaller fibroids with heavy menstrual bleeding are: Endometrial ablation Resection of submucosal fibroids during hysteroscopy Hysterectomy

Answer 66

For fibroids more than 3 cm, women need referral to gynaecology for investigation and management. Medical management options are: Symptomatic management with NSAIDs and tranexamic acid (antifibrinolytics) Mirena coil – depending on the size and shape of the fibroids and uterus Combined oral contraceptive Cyclical oral progestogens Surgical options for larger fibroids are: Uterine artery embolisation (may preserve fertility) Myomectomy (usually preserves fertility) Hysterectomy Radio frequency ablation to induce necrosis of the fibroid GnRH agonists, such as goserelin (Zoladex) or leuprorelin (Prostap), may be used to reduce the size of fibroids before surgery. They work by inducing a menopause-like state and reducing the amount of oestrogen maintaining the fibroid. Usually, GnRH agonists are only used short term, for example, to shrink a fibroid before myomectomy.

Answer 67

Uterine artery embolisation is a surgical option for larger fibroids, performed by interventional radiologists. The radiologist inserts a catheter into an artery, usually the femoral artery. This catheter is passed through to the uterine artery under X-ray guidance. Once in the correct place, particles are injected that cause a blockage in the arterial supply to the fibroid. This starves the fibroid of oxygen and causes it to shrink.

Answer 68

Myomectomy involves surgically removing the fibroid via laparoscopic (keyhole) surgery or laparotomy (open surgery). Myomectomy is the only treatment known to potentially improve fertility in patients with fibroids. Endometrial ablation can be used to destroy the endometrium. Second generation, non-hysteroscopic techniques are used, such as balloon thermal ablation. This involves inserting a specially designed balloon into the endometrial cavity and filling it with high-temperature fluid that burns the endometrial lining of the uterus. Hysterectomy involves removing the uterus and fibroids. Hysterectomy may be by laparoscopy (keyhole surgery), laparotomy or vaginal approach. The ovaries may be removed or left depending on patient preference, risks and benefits.

Answer 69

Myomectomy

Answer 70

Heavy menstrual bleeding, often with iron deficiency anaemia Reduced fertility Pregnancy complications, such as miscarriages, premature labour and obstructive delivery Constipation Urinary outflow obstruction and urinary tract infections Red degeneration of the fibroid Torsion of the fibroid, usually affecting pedunculated fibroids Malignant change to a leiomyosarcoma is very rare (<1%)

Answer 71

Ischaemia, infarction and necrosis of the fibroid due to disrupted blood supply.

Answer 72

Red degeneration is more likely to occur in larger fibroids (above 5 cm) during the second and third trimester of pregnancy. Red degeneration may occur as the fibroid rapidly enlarges during pregnancy, outgrowing its blood supply and becoming ischaemic. It may also occur due to kinking in the blood vessels as the uterus changes shape and expands during pregnancy.

Answer 73

Red degeneration presents with severe abdominal pain, low-grade fever, tachycardia and often vomiting. Management is supportive, with rest, fluids and analgesia.

Answer 74

Red degeneration of a fibroid

Answer 75

Endometriosis is a condition where there is ectopic endometrial tissue outside the uterus.

Answer 76

as an endometrioma.

Answer 77

“chocolate cysts”.

Answer 78

Adenomyosis refers to endometrial tissue within the myometrium (muscle layer) of the uterus.

Answer 79

The exact cause of endometriosis is not clear, but there are several theories. No specific genes have been found to cause endometriosis; however, there does seem to be a genetic component to developing the condition. One notable theory for the cause of ectopic endometrial tissue is that during menstruation, the endometrial lining flows backwards, through the fallopian tubes and out into the pelvis and peritoneum. This is called retrograde menstruation. The endometrial tissue then seeds itself around the pelvis and peritoneal cavity. Other possible methods for endometrial tissue exiting the uterus have been proposed: - Embryonic cells destined to become endometrial tissue may remain in areas outside the uterus during the development of the fetus, and later develop into ectopic endometrial tissue. - There may be spread of endometrial cells through the lymphatic system, in a similar way to the spread of cancer. - Cells outside the uterus somehow change, in a process called metaplasia, from typical cells of that organ into endometrial cells.

Answer 80

CYCLICAL PAIN - DULL, HEAVY BURNING PAIN: Endometrial tissue outside the uterus responds to hormones in the same way as endometrial tissue in the uterus. It bleeds during menstruation as it sheds (the same way it does in the uterus) causing irritation and inflammation of the surrounding tissues. BLOOD IN URINE AND STOOLS Endometrium deposits in the bowel or bladder CHRONIC NON-CYCLICAL PAIN - SHARP, STABBING OR PULLING PAIN ASSOCIATED WITH NAEUSEA: Adhesions form from localised bleeding and inflammation. Scar tissue binds organs together (e.g. ovaries to peritoneum, uterus to bowel) REDUCED FERTILITY: Unclear - may be due to adhesions around the ovaries and fallopian tubes blocking the release of eggs or kinking the fallopian tubes obstructing the route to the uterus. Endometriomas in the ovaries may also damage eggs or prevent effective ovulation.

Answer 81

Asymptomatic Cyclical: abdominal or pelvic pain, urinary symptoms and bowel symptoms Deep dyspareunia (pain on deep sexual intercourse) Dysmenorrhea (painful periods) Infertility Cyclical bleeding from other sites such as haematuria O/E: Endometrial tissue visable in the bagina and on speculum examination, particularly in the posterior fornix, a fixed cervix on bimanual examination, tenderness in the vagina, cervic and adnexa

Answer 82

Endometrial tissue visible in the vagina on speculum examination, particularly in the posterior fornix A fixed cervix on bimanual examination Tenderness in the vagina, cervix and adnexa

Answer 83

Pelvic ultrasound may reveal large endometriomas and chocolate cysts. Ultrasound scans are often unremarkable in patients with endometriosis. Patients with suspected endometriosis need referral to a gynaecologist for laparoscopy. Laparoscopic surgery is the gold standard way to diagnose abdominal and pelvic endometriosis. A definitive diagnosis can be established with a biopsy of the lesions during laparoscopy. Laparoscopy has the added benefit of allowing the surgeon to remove deposits of endometriosis and potentially improve symptoms.

Answer 84

American Society of Reproductive Medicine (ASRM) Stage 1: Small suoerficial lesions Stage 2 Mild but deeper lesions than stage 1 Stage 3: Deeper lesion with lesions on the ovaries and mild adhesions Stage 4: Deep and large lesions affecting the ovaries with extensive adhesions

Answer 85

RCOG Green-top guideline 41 on chronic pelvic pain (2012), the ESHRE guidelines on endometriosis (2013) and the NICE clinical knowledge summaries (2020).

Answer 86

Establishing a diagnosis Proving a clear explanation Listening to the patient establishing ICE and building a partnership Analgesia as required for pain (NSAIDs and paracetomol first line)

Answer 87

Hormonal management options can be tried before establishing a definitive diagnosis with laparoscopy: Combined oral contractive pill, which can be used back to back without a pill-free period if helpful Progesterone only pill Medroxyprogesterone acetate injection (e.g. Depo-Provera) Nexplanon implant Mirena coil GnRH agonists

Answer 88

Laparoscopic surgery to excise or ablate the endometrial tissue and remove adhesions (adhesiolysis) The aim is to remove as much of the endometriosis as possible, treat adhesions and return the anatomy to normal. This improves fertility in some but not all women with endometriosis.

Answer 89

Laparoscopic surgery to excise or ablate the endometrial tissue and remove adhesions (adhesiolysis) Hysterectomy Laparoscopic treatment may improve fertility. Hormonal therapies may improve symptoms but not fertility.

Answer 90

Cyclical pain can be treated with hormonal medications that stop ovulation and reduce endometrial thickening. This can be achieved using the combined oral contraceptive pill, oral progesterone-only pill, the progestin depot injection, the progestin implant (Nexplanon) and the Mirena coil. The cyclical pain tends to improve after the menopause when the female sex hormones are reduced. Therefore, another treatment option for endometriosis is to induce a menopause-like state using GnRH agonists. Examples of GnRH agonists are goserelin (Zoladex) or leuprorelin (Prostap). They shut down the ovaries temporarily and can be useful in treating pain in many women. However, inducing the menopause has several side effects, such as hot flushes, night sweats and a risk of osteoporosis.

Answer 91

Hysterectomy and bilateral salpingo-opherectomy is the final surgical option. During the procedure, the surgeon will attempt to remove as much of the endometriosis as possible. Importantly, this is still not guaranteed to resolve symptoms. Removing the ovaries induces menopause, and this stops ectopic endometrial tissue responding to the menstrual cycle

Answer 92

Adenomyosis refers to endometrial tissue inside the myometrium (muscle layer of the uterus). It is more common in later reproductive years and those that have had several pregnancies (multiparous). It occurs in around 10% of women overall. It may occur alone, or alongside endometriosis or fibroids. The cause is not fully understood, and multiple factors are involved, including sex hormones, trauma and inflammation. The condition is hormone-dependent, and symptoms tend to resolve after menopause, similarly to endometriosis and fibroids.

Answer 93

Increased risk in multiparity

Answer 94

NON CYCLICAL = sharp, stabbing or pulling associated with nausea? Adhesions lead to a chronic, non-cyclical pain that can be sharp, stabbing or pulling and associated with nausea. CYCLICAL = dull, heavy, burning pain The cells of the endometrial tissue outside the uterus respond to hormones in the same way as endometrial tissue in the uterus during menstruation and shed as the endometrial tissue in the uterus sheds its lining and bleeds. This causes irritation and inflammation of the tissues around the sites of endometriosis. This results in the cyclical, dull, heavy or burning pain that occurs during menstruation in patients with endometriosis.

Answer 95

Adenomyosis typically presents with: Painful periods (dysmenorrhoea) Heavy periods (menorrhagia) Pain during intercourse (dyspareunia) It may also present with infertility or pregnancy-related complications. Around a third of patients are asymptomatic. Examination can demonstrate an enlarged and tender uterus. It will feel more soft than a uterus containing fibroids.

Answer 96

Transvaginal ultrasound of the pelvis is the first-line investigation for suspected adenomyosis. MRI and transabdominal ultrasound are alternative investigations where transvaginal ultrasound is not suitable. The gold standard is to perform a histological examination of the uterus after a hysterectomy. However, this is not usually a suitable way of establishing the diagnosis for obvious reasons.

Answer 97

Management of adenomyosis will depend on symptoms, age and plans for pregnancy. NICE recommend the same treatment for adenomyosis as for heavy menstrual bleeding. When the woman does not want contraception; treatment can be used during menstruation for symptomatic relief, with: Tranexamic acid when there is no associated pain (antifibrinolytic – reduces bleeding) Mefenamic acid when there is associated pain (NSAID – reduces bleeding and pain) Management when contraception is wanted or acceptable: Mirena coil (first line) Combined oral contraceptive pill Cyclical oral progestogens Progesterone only medications such as the pill, implant or depot injection may also be helpful. Other options are that may be considered by a specialist include: GnRH analogues to induce a menopause-like state Endometrial ablation Uterine artery embolisation Hysterectomy

Answer 98

Infertility Miscarriage Preterm birth Small for gestational age Preterm premature rupture of membranes Malpresentation Need for caesarean section Postpartum haemorrhage

Answer 99

Retrospective diagnosis of the end of mensturation

Answer 100

Postmenopause describes the period from 12 months after the final menstrual period onwards.

Answer 101

Perimenopause refers to the time around the menopause, where the woman may be experiencing vasomotor symptoms and irregular periods. Perimenopause includes the time leading up to the last menstrual period, and the 12 months afterwards. This is typically in women older than 45 years.

Answer 102

Premature menopause is menopause before the age of 40 years. It is the result of premature ovarian insufficiency.

Answer 103

Menopause is caused by a lack of ovarian follicular function, resulting in changes in the sex hormones associated with the menstrual cycle: Oestrogen and progesterone levels are low LH and FSH levels are high, in response to an absence of negative feedback from oestrogen

Answer 104

Decline in development of ovarian follicles Due to this decrease development there is reduced production of oestrogen by the follicles The decreased production of oestrogen results in decreased negative feedback on the pituitary gland, therefore more LH and FSH are produced. As the level of oestrogen falls in the perimenopausal period, there is an absence of negative feedback on the pituitary gland, and increasing levels of LH and FSH. The failing follicular development means ovulation does not occur (anovulation), resulting in irregular menstrual cycles. Without oestrogen, the endometrium does not develop, leading to a lack of menstruation (amenorrhoea). Lower levels of oestrogen also cause the perimenopausal symptoms.

Answer 105

Hot flushes Emotional lability or low mood Premenstrual syndrome Irregular periods Joint pains Heavier or lighter periods Vaginal dryness and atrophy Reduced libido

Answer 106

A lack of oestrogen increases the risk of certain conditions: Cardiovascular disease and stroke Osteoporosis Pelvic organ prolapse Urinary incontinence

Answer 107

A diagnosis of perimenopause and menopause can be made in women over 45 years with typical symptoms, without performing any investigations.

Answer 108

Women under 40 years with suspected premature menopause Women aged 40 – 45 years with menopausal symptoms or a change in the menstrual cycle

Answer 109

Two years after the last menstrual period in women under 50 One year after the last menstrual period in women over 50

Answer 110

Hormonal contraceptives do not affect the menopause, when it occurs or how long it lasts, although they may suppress and mask the symptoms. This can make diagnosing menopause in women on hormonal contraception more difficult.

Answer 111

Barrier methods Mirena or copper coil Progesterone only pill Progesterone implant Progesterone depot injection (under 45 years) Sterilisation

Answer 112

Consider combined oral contraceptive pills containing norethisterone or levonorgestrel in women over 40, due to the relatively lower risk of venous thromboembolism compared with other options.

Answer 113

Two key side effects of the progesterone depot injection (e.g. Depo-Provera): weight gain and reduced bone mineral density (osteoporosis). These side effects are unique to the depot and do not occur with other forms of contraception. Reduced bone mineral density makes the depot unsuitable for women over 45 years.

Answer 114

No treatment Hormone replacement therapy (HRT) Tibolone, a synthetic steroid hormone that acts as continuous combined HRT (only after 12 months of amenorrhoea) Clonidine, which act as agonists of alpha-adrenergic and imidazoline receptors Cognitive behavioural therapy (CBT) SSRI antidepressants, such as fluoxetine or citalopram Testosterone can be used to treat reduced libido (usually as a gel or cream) Vaginal oestrogen cream or tablets, to help with vaginal dryness and atrophy (can be used alongside systemic HRT) Vaginal moisturisers, such as Sylk, Replens and YES

Answer 115

Premature ovarian insufficiency is defined as menopause before the age of 40 years. It is the result of a decline in the normal activity of the ovaries at an early age. It presents with early onset of the typical symptoms of the menopause. Premature ovarian insufficiency is characterised by hypergonadotropic hypogonadism. Under-activity of the gonads (hypogonadism) means there is a lack of negative feedback on the pituitary gland, resulting in an excess of the gonadotropins (hypergonadotropism). Hormonal analysis will show: Raised LH and FSH levels (gonadotropins) Low oestradiol levels

Answer 116

Idiopathic (the cause is unknown in more than 50% of cases) Iatrogenic, due to interventions such as chemotherapy, radiotherapy or surgery (i.e. oophorectomy) Autoimmune, possibly associated with coeliac disease, adrenal insufficiency, type 1 diabetes or thyroid disease Genetic, with a positive family history or conditions such as Turner’s syndrome Infections such as mumps, tuberculosis or cytomegalovirus

Answer 117

Hormonal analysis will show: Raised LH and FSH levels (gonadotropins) Low oestradiol levels

Answer 118

Premature ovarian insufficiency presents with irregular menstrual periods, lack of menstrual periods (secondary amenorrhea) and symptoms of low oestrogen levels, such has hot flushes, night sweats and vaginal dryness.

Answer 119

NICE guidelines on menopause (2015) say premature ovarian insufficiency can be diagnosed in women younger than 40 years with typical menopausal symptoms plus elevated FSH. The FSH level needs to be persistently raised (more than 25 IU/l) on two consecutive samples separated by more than four weeks to make a diagnosis. The results are difficult to interpret in women taking hormonal contraception.

Answer 120

Cardiovascular disease Stroke Osteoporosis Cognitive impairment Dementia Parkinsonism

Answer 121

Management involves hormone replacement therapy (HRT) until at least the age of 51 HRT reduces the cardiovascular, osteoporosis, cognitive and psychological risks associated with premature menopause. It is worth noting there is still a small risk of pregnancy in women with premature ovarian failure, and contraception is still required. There are two options for HRT in women with premature ovarian insufficiency: Traditional hormone replacement therapy Combined oral contraceptive pill

Answer 122

Traditional hormone replacement therapy is associated with a lower blood pressure compared with the combined oral contraceptive pill. The combined pill may be more socially acceptable (less stigma for younger women) and additionally acts as contraception.

Answer 123

Hormone replacement therapy before the age of 50 is not considered to increase the risk of breast cancer compared with the general population, as women would ordinarily produce the same hormones at this age.

Answer 124

The risk of VTE can be reduced by using transdermal methods (i.e. patches).

Answer 125

Exogenous oestrogen is given to alleviate the symptoms associated with the decline in oestrogen levels during menopause and peri-menopause Progesterone needs to be given (in addition to oestrogen) to women that have a uterus. The primary purpose of adding progesterone is to prevent endometrial hyperplasia and endometrial cancer secondary to “unopposed” oestrogen.

Answer 126

Prevents endometrial hyperplasia and endometrial cancer secondary to unopposed oestrogen Only required for women who have a uterus

Answer 127

Women that still have periods should go on cyclical HRT, with cyclical progesterone and regular breakthrough bleeds.

Answer 128

Postmenopausal women with a uterus and more than 12 months without periods should go on continuous combined HRT.

Answer 129

Non-hormonal treatments may be tried initially, or used when there are contraindications to HRT. Options include: Lifestyle changes such as improving the diet, exercise, weight loss, smoking cessation, reducing alcohol, reducing caffeine and reducing stress Cognitive behavioural therapy (CBT) Clonidine, which is an agonist of alpha-adrenergic and imidazoline receptors SSRI antidepressants (e.g. fluoxetine) Venlafaxine, which is a selective serotonin-norepinephrine reuptake inhibitor (SNRI) Gabapentin

Answer 130

Clonidine act as an agonist of alpha-2 adrenergic receptors and imidazoline receptors in the brain. It lowers blood pressure and reduces the heart rate, and is also used as an antihypertensive medication. It can be helpful for vasomotor symptoms and hot flushes, particularly where there are contraindications to using HRT. Common side effects of clonidine are dry mouth, headaches, dizziness and fatigue. Sudden withdrawal can result in rapid increases in blood pressure and agitation.

Answer 131

Black cohosh, which may be a cause of liver damage Dong quai, which may cause bleeding disorders Red clover, which may have oestrogenic effects that would be concerning with oestrogen sensitive cancers Evening primrose oil, which has significant drug interactions and is linked with clotting disorders and seizures Ginseng may be used for mood and sleep benefits

Answer 132

Replacing hormones in premature ovarian insufficiency, even without symptoms Reducing vasomotor symptoms such as hot flushes and night sweats Improving symptoms such as low mood, decreased libido, poor sleep and joint pain Reducing risk of osteoporosis in women under 60 years

Answer 133

In women under 60 years, the benefits of HRT generally outweigh the risks. The key benefits to inform women of include: Improved vasomotor and other symptoms of menopause (including mood, urogenital and joint symptoms) Improved quality of life Reduced the risk of osteoporosis and fractures

Answer 134

Increased risk of breast cancer (particularly combined HRT – oestrogen-only HRT has a lower risk) Increased risk of endometrial cancer Increased risk of venous thromboembolism (2 – 3 times the background risk) Increased risk of stroke and coronary artery disease with long term use in older women The evidence is inconclusive about ovarian cancer, and if there is an increase in risk, it is minimal

Answer 135

The risks are not increased in women under 50 years compared with other women their age There is no risk of endometrial cancer in women without a uterus There is no increased risk of coronary artery disease with oestrogen-only HRT (the risk may even be lower with HRT)

Answer 136

The risk of endometrial cancer is greatly reduced by adding progesterone in women with a uterus

Answer 137

The risk of VTE is reduced by using patches rather than pills

Answer 138

Undiagnosed abnormal bleeding Endometrial hyperplasia or cancer Breast cancer Uncontrolled hypertension Venous thromboembolism Liver disease Active angina or myocardial infarction Pregnancy

Answer 139

Take a full history to ensure there are no contraindications Take a family history to assess the risk of oestrogen dependent cancers (e.g. breast cancer) and VTE Check the body mass index (BMI) and blood pressure Ensure cervical and breast screening is up to date Encourage lifestyle changes that are likely to improve symptoms and reduce risks

Answer 140

1. LOCAL OR SYSTEMIC SYMPTOMS Local symptoms: use topical treatments such as topical oestrogen cream or tablets Systemic symptoms: use systemic treatment – go to step 2 2. UTERUS OR NON UTERUS No uterus: use continuous estrogen-only HRT Has uterus: add progesterone (combined HRT) – go to step 3 3. BLEED IN LAST 12 MONTHS? Perimenopausal: give cyclical combined HRT Postmenopausal (more than 12 months since last period): give continuous combined HRT

Answer 141

Oestrogen is the critical component of HRT for reducing the symptoms of menopause. There are two options for delivering systemic oestrogen: - Oral (tablets) - Transdermal (patches or gels) Patches are more suitable for women with poor control on oral treatment, higher risk of venous thromboembolism, cardiovascular disease and headaches.

Answer 142

There are three options for delivering progesterone for endometrial protection: 1. Oral (tablets) 2. Transdermal (patches) 3. Intrauterine system (e.g. Mirena coil) Cyclical combined HRT options include sequential tablets or patches containing continuous oestrogen with progesterone added for specific periods during the cycle. The Mirena coil is licensed for four years for endometrial protection, after which time it needs replacing. The Mirena coil has the added benefits of contraception and treating heavy menstrual periods. It can cause irregular bleeding and spotting in the first few months after insertion. This usually settles with time and many women become amenorrhoeic.

Answer 143

endometriosis adenomyosis pelvic inflammatory disease intrauterine devices* fibroids

Answer 144

In primary dysmenorrhoea there is no underlying pelvic pathology. It affects up to 50% of menstruating women and usually appears within 1-2 years of the menarche. Excessive endometrial prostaglandin production is thought to be partially responsible. Features pain typically starts just before or within a few hours of the period starting suprapubic cramping pains which may radiate to the back or down the thigh Secondary dysmenorrhoea typically develops many years after the menarche and is the result of an underlying pathology. In contrast to primary dysmenorrhoea the pain usually starts 3-4 days before the onset of the period.

Answer 145

On examination, you find that the patient is mildly overweight; her abdomen is soft with no obvious masses. On vaginal examination you find a normal-sized, fixed retroverted uterus, and there is tenderness in the posterior vaginal fornix. Both adnexa appear normal.

Answer 146

Transvaginal ultrasound

Answer 147

Vaginal atrophy

Answer 148

Functional type - follicular

Answer 149

Follicular (most common) Corpus leuteum cyst (usually seen in early pregnancy when corpus leuteum fails to break down)

Answer 150

Sudden onset abdominal pain typically occuring during exercise

Answer 151

Urinary frequency Constipation Pedal odema

Answer 152

Red degeneration of the fibroid (haemorrhage into the fibroid) Sarcomatous change Torsion of the fibroid

Answer 153

N&V - hyperemisis gravidarum Abnormal vaginal discharge including bleeding, watery Reduced feotal movement after 20 weeks gestation

Answer 154

Rectum prolapses into the vagina due to a defect in the posterior vaginal wall

Answer 155

Use lubricant and warm speculum Hold speculum in dominant hand Part labia with nondominant hand Slowly insert and open speculum blades to visualize the cervix

Answer 156

Separate labia with gloved left hand Slowly insert index finger and middle finger into vagina and palpate the cervix Left hand then palpates uterus and adnexa abdominally

Answer 157

Escherichia coli

Answer 158

Bartholin's glands are situated within the vestibule, just lateral to the introitus and normally function to secrete a lubricating fluid. Bartholin's gland cyst: occurs when the duct from the gland becomes blocked, resulting in palpable swelling and pain at the site of the Bartholin's gland

Answer 159

Nabothian cysts are cysts on the cervix that occur when the squamous-cell epithelium of the cervix slightly covers the columnar epithelium. As the columnar epithelium secretes mucous, the mucous becomes trapped, and cysts form. The cysts contain yellow/amber mucous and are usually located around the os where the epitheliums transition. They are a normal finding, particularly in women who have had children.

Answer 160

The 'Whirlpool' sign is a characteristic sign of ovarian torsion that can be seen on ultrasound or CT scan. It demonstrates the twisting of the ovarian pedicle

Answer 161

An ovarian cyst

Answer 162

These can be taken during the luteal phase of the menstrual cycle (days 15–28).

Answer 163

Chlamydia trachomatis or Neisseria gonorrhoeae

Answer 164

Prolapse is the result of weakness and lengthening of the ligaments and muscles surrounding the uterus, rectum and bladder.

Answer 165

Weakness and lengthening of the ligaments and muscles surrounding the uterus, rectum and bladder.

Answer 166

Uterine prolapse is where the uterus itself descends into the vagina.

Answer 167

Vault prolapse occurs in women that have had a hysterectomy, and no longer have a uterus. The top of the vagina (the vault) descends into the vagina.

Answer 168

Rectoceles are caused by a defect in the posterior vaginal wall, allowing the rectum to prolapse forwards into the vagina.

Answer 169

Rectoceles are particularly associated with constipation. Women can develop faecal loading in the part of the rectum that has prolapsed into the vagina. Loading of faeces results in significant constipation, urinary retention (due to compression on the urethra) and a palpable lump in the vagina.

Answer 170

Women may use their fingers to press the lump backwards, correcting the anatomical position of the rectum, and allowing them to open their bowels.

Answer 171

Cystoceles are caused by a defect in the anterior vaginal wall, allowing the bladder to prolapse backwards into the vagina.

Answer 172

Prolapse of the urethra

Answer 173

Prolapse of both the bladder and the urethra

Answer 174

Multiple vaginal deliveries Instrumental, prolonged or traumatic delivery Advanced age and postmenopause status Obesity Chronic respiratory disease causing coughing Chronic constipation causing straining

Answer 175

A feeling of “something coming down” in the vagina A dragging or heavy sensation in the pelvis Urinary symptoms, such as incontinence, urgency, frequency, weak stream and retention Bowel symptoms, such as constipation, incontinence and urgency Sexual dysfunction, such as pain, altered sensation and reduced enjoyment Women may have identified a lump or mass in the vagina, and often will already be pushing it back up themselves. They may notice the prolapse will become worse on straining or bearing down.

Answer 176

Ideally, the patient should empty their bladder and bowel before examination of a prolapse. When examining for pelvic organ prolapse, various positions may be attempted, including the dorsal and left lateral position. A Sim’s speculum is a U-shaped, single-bladed speculum that can be used to support the anterior or posterior vaginal wall while the other vaginal walls are examined. It is held on the anterior wall to examine for a rectocele, and the posterior wall for a cystocele. The women can be asked to cough or “bear down” to assess the full descent of the prolapse.

Answer 177

Grade 0: Normal Grade 1: The lowest part is more than 1cm above the introitus Grade 2: The lowest part is within 1cm of the introitus (above or below) Grade 3: The lowest part is more than 1cm below the introitus, but not fully descended Grade 4: Full descent with eversion of the vagina

Answer 178

The severity of a uterine prolapse can be graded using the pelvic organ prolapse quantification (POP-Q) system

Answer 179

A prolapse extending beyond the introitus can be referred to as uterine procidentia.

Answer 180

Conservative management Vaginal pessary Surgery

Answer 181

Physiotherapy (pelvic floor exercises) Weight loss Lifestyle changes for associated stress incontinence, such as reduced caffeine intake and incontinence pads Treatment of related symptoms, such as treating stress incontinence with anticholinergic mediations Vaginal oestrogen cream

Answer 182

Vaginal pessaries are inserted into the vagina to provide extra support to the pelvic organs. They can create a significant improvement in symptoms and can easily be removed and replaced if they cause any problems.

Answer 183

Women often have to try a few types of pessary before finding the correct comfort and symptom relief. Pessaries should be removed and cleaned or changed periodically (e.g. every four months). They can cause vaginal irritation and erosion over time. Oestrogen cream helps protect the vaginal walls from irritation.

Answer 184

Ring pessaries are a ring shape, and sit around the cervix holding the uterus up Shelf and Gellhorn pessaries consist of a flat disc with a stem, that sits below the uterus with the stem pointing downwards Cube pessaries are a cube shape Donut pessaries consist of a thick ring, similar to a doughnut Hodge pessaries are almost rectangular. One side is hooked around the posterior aspect of the cervix and the other extends into the vagina.

Answer 185

Pain, bleeding, infection, DVT and risk of anaesthetic Damage to the bladder or bowel Recurrence of the prolapse Altered experience of sex

Answer 186

Chronic pain Altered sensation Dyspareunia (painful sex) for the women or her partner Abnormal bleeding Urinary or bowel problems Women presenting with possible complications of mesh repair should be referred to a specialist for assessment and management.

Answer 187

Urge incontinence is caused by overactivity of the detrusor muscle of the bladder. Urge incontinence is also known as overactive bladder. The typical description is of suddenly feeling the urge to pass urine, having to rush to the bathroom and not arriving before urination occurs. Women with urge incontinence are very conscious about always having access to a toilet, and may avoid activities or places where they may not have easy access. This can have a significant impact on their quality of life, and stop them doing work and leisure activities.

Answer 188

The pelvic floor consists of a sling of muscles that support the contents of the pelvic. There are three canals through the centre of the female pelvic floor: the urethral, vaginal and rectal canals. When the muscles of the pelvic floor are weak, the canals become lax, and the organs are poorly supported within the pelvis. Stress incontinence is due to weakness of the pelvic floor and sphincter muscles. This allows urine to leak at times of increased pressure on the bladder. The typical description of stress incontinence is urinary leakage when laughing, coughing or surprised.

Answer 189

Mixed incontinence refers to a combination of urge incontinence and stress incontinence. It is crucial to identify which of the two is having the more significant impact and address this first.

Answer 190

Overflow incontinence can occur when there is chronic urinary retention due to an obstruction to the outflow of urine. Chronic urinary retention results in an overflow of urine, and the incontinence occurs without the urge to pass urine. It can occur with anticholinergic medications, fibroids, pelvic tumours and neurological conditions such as multiple sclerosis, diabetic neuropathy and spinal cord injuries. Overflow incontinence is more common in men, and rare in women. Women with suspected overflow incontinence should be referred for urodynamic testing and specialist management.

Answer 191

Increased age Postmenopausal status Increase BMI Previous pregnancies and vaginal deliveries Pelvic organ prolapse Pelvic floor surgery Neurological conditions, such as multiple sclerosis Cognitive impairment and dementia

Answer 192

Caffeine consumption Alcohol consumption Medications Body mass index (BMI)

Answer 193

Frequency of urination Frequency of incontinence Nighttime urination Use of pads and changes of clothing

Answer 194

Examination should assess the pelvic tone and examine for: Pelvic organ prolapse Atrophic vaginitis Urethral diverticulum Pelvic masses During the examination, ask the patient to cough and watch for leakage from the urethra. The strength of the pelvic muscle contractions can be assessed during a bimanual examination by asking the woman to squeeze against the examining fingers.

Answer 195

By the modified Oxford system

Answer 196

0: No contraction 1: Faint contraction 2: Weak contraction 3: Moderate contraction with some resistance 4: Good contraction with resistance 5: Strong contraction, a firm squeeze and drawing inwards

Answer 197

A bladder diary should be completed, tracking fluid intake and episodes of urination and incontinence over at least three days. There should be a mix of work and leisure days. Urine dipstick testing should be performed to assess for infection, microscopic haematuria and other pathology. Post-void residual bladder volume should be measured using a bladder scan to assess for incomplete emptying. Urodynamic testing can be used to investigate patients with urge incontinence not responding to first-line medical treatments, difficulties urinating, urinary retention, previous surgery or an unclear diagnosis. It is not always required where the diagnosis is possible based on the history and examination.

Answer 198

Urodynamic tests are a way of objectively assessing the presence and severity of urinary symptoms. Patients need to stop taking any anticholinergic and bladder related medications around five days before the tests. A thin catheter is inserted into the bladder, and another into the rectum. These two catheters can measure the pressures in the bladder and rectum for comparison. The bladder is filled with liquid, and various outcome measures are taken

Answer 199

Cystometry measures the detrusor muscle contraction and pressure Uroflowmetry measures the flow rate Leak point pressure is the point at which the bladder pressure results in leakage of urine. The patient is asked to cough, move or jump when the bladder is filled to various capacities. This assesses for stress incontinence. Post-void residual bladder volume tests for incomplete emptying of the bladder Video urodynamic testing involves filling the bladder with contrast and taking xray images as the bladder is emptied. Theses are only performed where necessary and not a routine part of urodynamic testing.

Answer 200

Avoiding caffeine, diuretics and overfilling of the bladder Avoid excessive or restricted fluid intake Weight loss (if appropriate) Supervised pelvic floor exercises for at least three months before considering surgery Surgery Duloxetine is an SNRI antidepressant used second line where surgery is less preferred

Answer 201

Pelvic floor exercises are used to strengthen the muscles of the pelvic floor. They increase the tone and improve the support for the bladder and bowel. Pelvic floor exercises should be supervised by an appropriate professional, such as a specialist nurse or physiotherapist. Women should aim for at least eight contractions, three times daily.

Answer 202

Tension-free vaginal tape (TVT) procedures involve a mesh sling looped under the urethra and up behind the pubic symphysis to the abdominal wall. This supports the urethra, reducing stress incontinence. Autologous sling procedures work similarly to TVT procedures but a strip of fascia from the patient’s abdominal wall is used rather than tape Colposuspension involves stitches connecting the anterior vaginal wall and the pubic symphysis, around the urethra, pulling the vaginal wall forwards and adding support to the urethra Intramural urethral bulking involves injections around the urethra to reduce the diameter and add support Where the stress incontinence is caused by a neurological disorder or other surgical methods have failed, specialist centres may offer an operation to create an artificial urinary sphincter. This involves a pump inserted into the labia that inflates and deflates a cuff around the urethra, allowing women to control their continence manually.

Answer 203

Bladder retraining (gradually increasing the time between voiding) for at least six weeks is first-line Anticholinergic medication, for example, oxybutynin, tolterodine and solifenacin Mirabegron is an alternative to anticholinergic medications Invasive procedures where medical treatment fails

Answer 204

Anticholinergic medications need to be used carefully, as they have anticholinergic side effects. These include dry mouth, dry eyes, urinary retention, constipation and postural hypotension. Importantly they can also lead to a cognitive decline, memory problems and worsening of dementia, which can be very problematic in older, more frail patients.

Answer 205

Uncontrolled hypertension. Blood pressure needs to be monitored regularly during treatment. It works as a beta-3 agonist, stimulating the sympathetic nervous system, leading to raised blood pressure. This can lead to a hypertensive crisis and an increased risk of TIA and stroke.

Answer 206

Botulinum toxin type A injection into the bladder wall Percutaneous sacral nerve stimulation involves implanting a device in the back that stimulates the sacral nerves Augmentation cystoplasty involves using bowel tissue to enlarge the bladder Urinary diversion involves redirecting urinary flow to a urostomy on the abdomen

Answer 207

Atrophic vaginitis refers to dryness and atrophy of the vaginal mucosa related to a lack of oestrogen. Atrophic vaginitis can also be referred to as genitourinary syndrome of menopause. It occurs in women entering the menopause.

Answer 208

The epithelial lining of the vagina and urinary tract responds to oestrogen by becoming thicker, more elastic and producing secretions. As women enter the menopause, oestrogen levels fall, resulting in the mucosa becoming thinner, less elastic and more dry. The tissue is more prone to inflammation. There are also changes in the vaginal pH and microbial flora that can contribute to localised infections. Oestrogen also helps maintain healthy connective tissue around the pelvic organs, and a lack of oestrogen can contribute to pelvic organ prolapse and stress incontinence.

Answer 209

Itching Dryness Dyspareunia (discomfort or pain during sex) Bleeding due to localised inflammation

Answer 210

Older women presenting with recurrent urinary tract infections, stress incontinence or pelvic organ prolapse. Treatment with topical oestrogen where appropriate may improve the symptoms of these conditions. It is worth asking about symptoms of vaginal dryness and discomfort, as women will often be reluctant to bring it up during a consultation. It is straightforward to treat and can make a big difference to their quality of life.

Answer 211

Pale mucosa Thin skin Reduced skin folds Erythema and inflammation Dryness Sparse pubic hair

Answer 212

Vaginal lubricants can help symptoms of dryness. Examples include Sylk, Replens and YES. Topical oestrogen can make a big difference in symptoms. Options include: Estriol cream, applied using an applicator (syringe) at bedtime Estriol pessaries, inserted at bedtime Estradiol tablets (Vagifem), once daily Estradiol ring (Estring), replaced every three months

Answer 213

Topical oestrogen shares many contraindications with systemic HRT, such as breast cancer, angina and venous thromboembolism. It is unclear whether long term use of topical oestrogen increases the risk of endometrial hyperplasia and endometrial cancer. Women should be monitored at least annually, with a view of stopping treatment whenever possible.

Answer 214

Androgen insensitivity syndrome

Answer 215

Following chickenpox exposure in a non-immune pregnant woman, varicella-zoster immunoglobulin (VZIG) is only effective up to 10 days post-exposure

Answer 216

Hypothalamic

Answer 217

Turner syndrome, a condition that affects only females, results when one of the X chromosomes (sex chromosomes) is missing or partially missing. Turner syndrome can cause a variety of medical and developmental problems, including short height, failure of the ovaries to develop and heart defects

Answer 218

Consider gonadal dysgenesis (e.g. Turner's syndrome)

Answer 219

Transdermal HRT

Answer 220

Menorrhagia - intrauterine system (Mirena) is first-line

Answer 221

GnRH agonists lead to the down-regulation of GnRH receptors, thus reducing oestrogen (and androgen) production. This reduces the symptoms of endometriosis as oestrogen thickens the uterine lining.

Answer 222

PCOS should be diagnosed if 2/3 of the following criteria are present: Infrequent or no ovulation (thus oligomenorrhoea is the correct answer in this scenario) ROTTERDAM CRITERIA Clinical or biochemical signs of hyperandrogenism or elevated levels of total or free testosterone (no mention of 'low levels of oestrogen') Polycystic ovaries on ultrasonography or increased ovarian volume (over 10cm3)

Answer 223

hirsutism, alopecia, acne vulgaris occurring after adolescence

Answer 224

either continuously or during the luteal phase

Answer 225

Constitutional delay i.e. a late bloomer, has secondary sexual characteristics Anatomical i.e. mullerian agenesis (patient develops secondary sexual characteristics and has variable absence of female sexual organs) Imperforate hymen (characterised by cyclical pain and the classic bluish bulging membrane on physical examination) Transverse vaginal septae (characterised by cyclical pain and retrograde menstruation) Turner syndrome (XO chromosome) Testicular feminisation syndrome (XY genotype, no internal female organs) Kallmann syndrome (failure to secrete GNRH)

Answer 226

Pregnancy Patient is using contraception Menopause Lactational amenorrhoea Hypothalamic amenorrhoea (suppression of GnRH due to stress, excessive exercise, eating disorder) Endocrinological (hyperthyroidism, polycystic ovary disease, Cushing's syndrome, hyperprolactinaemia, hypopituitarism) Premature ovarian failure (autoimmune, chemotherapy, radiation therapy) Asherman's syndrome (iatrogenic intrauterine adhesions/cervical stenosis)

Answer 227

Pregnancy test FSH/LH (if FSH is >20 in a woman <40 may suggest premature ovarian failure, if both are low it suggests a hypothalamic cause) Thyroid function tests Prolactin Pelvic USS

Answer 228

Patient has never had a period and Is aged 14 or older with no secondary sexual characteristics, Or over 16 if secondary sexual characteristics are present.

Answer 229

the patient has had no periods for >6 months but has had periods in the past.

Answer 230

Vaginal mucosa becomes drier and thinner. This can then bleed, especially when there is contact on the mucosa such as during intercourse, leading to symptoms such as post-coital bleeding and dyspareunia.

Answer 231

The combined oral contraceptive pill or a progestogen should be tried

Answer 232

Subfertility Diabetes mellitus Stroke & transient ischaemic attack Coronary artery disease Obstructive sleep apnoea Endometrial cancer

Answer 233

Endometriosis

Answer 234

Female genital mutilation (FGM) involves surgically changing the genitals of a female for non-medical reasons. FGM is a cultural practice that usually occurs in girls before puberty. It is a form of child abuse and a safeguarding issue.

Answer 235

Female genital mutilation is illegal as stated in the Female Genital Mutilation Act 2003, and there is a legal requirement for healthcare professionals to report cases of FGM to the police.

Answer 236

FGM is a common cultural practice in many African countries. Somalia has the highest levels of FGM in any country. Other countries with high rates are Ethiopia, Sudan and Eritrea. It also occurs in Yemen, Kurdistan, Indonesia and various parts of South and Western Asia.

Answer 237

Removal of part or all of the clitoris.

Answer 238

Removal of part or all of the clitoris and labia minora. The labia majora may also be removed

Answer 239

Narrowing or closing the vaginal orifice (infibulation)

Answer 240

All other unnecessary procedures to the female genitalia

Answer 241

It is important to recognise risk factors for FGM to identify and ideally prevent cases from occurring. Two key risk factors to bear in mind are coming from a community that practise FGM and having relatives affected by FGM. There are scenarios where it is worth considering the risk of FGM: Pregnant women with FGM with a possible female child Siblings or daughters of women or girls affected by FGM Extended trips with infants or children to areas where FGM is practised Women that decline examination or cervical screening New patients from communities that practise FGM Women may also present with the complications of FGM.

Answer 242

Pain Bleeding Infection Swelling Urinary retention Urethral damage and incontinence

Answer 243

Vaginal infections, such as bacterial vaginosis Pelvic infections Urinary tract infections Dysmenorrhea (painful menstruation) Sexual dysfunction and dyspareunia (painful sex) Infertility and pregnancy-related complications Significant psychological issues and depression Reduced engagement with healthcare and screening

Answer 244

It is essential to educate patients and relatives that FGM is illegal in the UK. Discuss the health consequences of FGM. It is mandatory to report all cases of FGM in patients under 18 to the police. Other services should also be contacted: Social services and safeguarding Paediatrics Specialist gynaecology or FGM services Counselling In patients over 18, there needs to be careful consideration about whether to report cases to the police or social services. The RCOG recommends using a risk assessment tool to tackle this issue which includes considering whether the patient has female relatives that may be at risk. If the unborn child of a pregnant woman affected by FGM is considered to be at risk, a referral should be made.

Answer 245

A de-infibulation surgical procedure may be performed by a specialist in FGM in cases of type 3 FGM. This aims to correct the narrowing or closure of the vaginal orifice, improve symptoms and try to restore normal function.

Answer 246

Re-infibulation (re-closure of the vaginal orifice) could be requested after childbirth. Performing this procedure is illegal

Answer 247

The three features of Meig's syndrome are: a benign ovarian tumour ascites pleural effusion It is a rare condition usually occurring in woman over the age of 40 years and the ovarian tumour is generally a fibroma. It is managed by the surgical removal of the tumour, however the ascites and pleural effusion may need to be drained first to allow symptomatic relief and improve pulmonary function before the anaesthetic. It has excellent prognosis due to the benign nature of the tumour.

Answer 248

At menopause (and in premature ovarian failure), ovarian function ceases, leading to high levels of FSH due to the removal of the negative feedback mechanisms.

Answer 249

Functional ovarian cysts related to the fluctuating hormones of the menstrual cycle, and are very common in premenopausal women. The vast majority of ovarian cysts in premenopausal women are benign. Cysts in postmenopausal women are more concerning for malignancy and need further investigation.

Answer 250

Anovulation Hyperandrogenism Polycystic ovaries on ultrasound

Answer 251

Most ovarian cysts are asymptomatic. Cysts are often found incidentally on pelvic ultrasound scans. Occasionally, ovarian cysts can cause vague symptoms of: Pelvic pain Bloating Fullness in the abdomen A palpable pelvic mass (particularly with very large cysts such as mucinous cystadenomas) Ovarian cysts may present with acute pelvic pain if there is ovarian torsion, haemorrhage or rupture of the cyst.

Answer 252

Type of functional cyst Follicular cysts represent the developing follicle. When these fail to rupture and release the egg, the cyst can persist. Follicular cysts are the most common ovarian cyst, they are harmless and tend to disappear after a few menstrual cycles. Typically they have thin walls and no internal structures, giving a reassuring appearance on the ultrasound.

Answer 253

Type of functional cysts Corpus luteum cysts occur when the corpus luteum fails to break down and instead fills with fluid. They may cause pelvic discomfort, pain or delayed menstruation. They are often seen in early pregnancy.

Answer 254

Serous Cystadenoma Mucinous Cystadenoma Endometrioma Dermoid Cysts / Germ Cell Tumours Sex Cord-Stromal Tumours

Answer 255

Endometrioma These are lumps of endometrial tissue within the ovary, occurring in patients with endometriosis. They can cause pain and disrupt ovulation.

Answer 256

Sertoli–Leydig cell tumours and granulosa cell tumours

Answer 257

Abdominal bloating Reduce appetite Early satiety Weight loss Urinary symptoms Pain Ascites Lymphadenopathy

Answer 258

Less than 5cm cysts will almost always resolve within three cycles. They do not require a follow-up scan.

Answer 259

5cm to 7cm: Require routine referral to gynaecology and yearly ultrasound monitoring.

Answer 260

Consider an MRI scan or surgical evaluation as they can be difficult to characterise with ultrasound.

Answer 261

Cysts in postmenopausal women generally require correlation with the CA125 result and referral to a gynaecologist. When there is a raised CA125, this should be a two-week wait suspected cancer referral. Simple cysts under 5cm with a normal CA125 may be monitored with an ultrasound every 4 – 6 months.

Answer 262

with an ultrasound every 4 – 6 months.

Answer 263

Persistent or enlarging cysts may require surgical intervention (usually with laparoscopy). Surgery may involve removing the cyst (ovarian cystectomy), possibly along with the affected ovary (oophorectomy).

Answer 264

Consider complications when patients present with acute onset pain. The main complications are: Torsion Haemorrhage into the cyst Rupture, with bleeding into the peritoneum

Answer 265

Ovarian torsion is a condition where the ovary twists in relation to the surrounding connective tissue, fallopian tube and blood supply (the adnexa)

Answer 266

Ovarian torsion is usually due to an ovarian mass larger than 5cm, such as a cyst or a tumour. It is more likely to occur with benign tumours. It is also more likely to occur during pregnancy.

Answer 267

Ovarian torsion can also happen with normal ovaries in younger girls before menarche (the first period), when girls have longer infundibulopelvic ligaments that can twist more easily.

Answer 268

Twisting of the adnexa and blood supply to the ovary leads to ischaemia. If the torsion persists, necrosis will occur, and the function of that ovary will be lost. Therefore, ovarian torsion is an emergency, where a delay in treatment can have significant consequences. Prompt diagnosis and management is essential.

Answer 269

The main presenting feature is sudden onset severe unilateral pelvic pain. The pain is constant, gets progressively worse and is associated with nausea and vomiting. The pain is not always severe, and ovarian torsion can take a milder and more prolonged course. Occasionally, the ovary can twist and untwist intermittently, causing pain that comes and goes. On examination there will be localised tenderness. There may be a palpable mass in the pelvis, although the absence of a mass does not exclude the diagnosis.

Answer 270

Pelvic ultrasound is the initial investigation of choice. Transvaginal is ideal, but transabdominal can be used where transvaginal is not possible. It may show “whirlpool sign”, free fluid in pelvis and oedema of the ovary. Doppler studies may show a lack of blood flow. The definitive diagnosis is made with laparoscopic surgery.

Answer 271

Patients need emergency admission under gynaecology for urgent investigation and management. Depending on the duration and severity of the illness they require laparoscopic surgery to either: Un-twist the ovary and fix it in place (detorsion) Remove the affected ovary (oophorectomy) The decision whether to save the ovary or remove it is made during the surgery, based on a visual inspection of the ovary. Laparotomy may be required where there is a large ovarian mass or malignancy is suspected.

Answer 272

A delay in treating ovarian torsion can result in loss of function of that ovary. The other ovary can usually compensate, so fertility is not typically affected. Where this is the only functioning ovary, loss of function leads to infertility and menopause. Where a necrotic ovary is not removed, it may become infected, develop an abscess and lead to sepsis. Additionally it may rupture, resulting in peritonitis and adhesions.

Answer 273

Cervical ectropion can also be called cervical ectopy or cervical erosion. Cervical ectropion occurs when the columnar epithelium of the endocervix (the canal of the cervix) has extended out to the ectocervix (the outer area of the cervix). The lining of the endocervix becomes visible on examination of the cervix using a speculum. This lining has a different appearance to the normal endocervix.

Answer 274

The cells of the endocervix (columnar epithelial cells) are more fragile and prone to trauma. They are more likely to bleed with sexual intercourse. This means cervical ectropion often presents with postcoital bleeding

Answer 275

Cervical ectropion is associated with higher oestrogen levels, and therefore, is more common in younger women, the combined contraceptive pill and pregnancy.

Answer 276

Many cervical ectropion are asymptomatic, and they are found incidentally during speculum examination for other reasons, for example, smear tests. Ectropion may present with increased vaginal discharge, vaginal bleeding or dyspareunia (pain during sex). Intercourse is a common cause of minor trauma to the ectropion, triggering episodes of postcoital bleeding. Examination of the cervix will reveal a well-demarcated border between the redder, velvety columnar epithelium extending from the os (opening), and the pale pink squamous epithelium of the ectocervix. This border is the transformation zone.

Answer 277

Asymptomatic ectropion require no treatment. Ectropion will typically resolve as the patient gets older, stops the pill or is no longer pregnant. Having a cervical ectropion is not a contraindication to the combined contraceptive pill. Problematic bleeding is an indication for the treatment of cervical ectropion. Treatment involves cauterisation of the ectropion using silver nitrate or cold coagulation during colposcopy.

Answer 278

Cervical ectropian

Answer 279

Cysts can become infected, forming a Bartholin’s abscess. A Bartholin’s abscess will be hot, tender, red and potentially draining pus.

Answer 280

The swelling is typically unilateral and forms a fluid-filled cyst between 1 – 4 cm.

Answer 281

The Bartholin’s glands are a pair glands located either side of the posterior part of the vaginal introitus (the vaginal opening). They are usually pea-sized and not palpable. They produce mucus to help with vaginal lubrication.

Answer 282

Bartholin’s cysts will usually resolve with simple treatment such as good hygiene, analgesia and warm compresses. Incision is generally avoided, as the cyst will often reoccur. A biopsy may be required if vulval malignancy needs to be excluded (particularly in women over 40 years).

Answer 283

History and examination

Answer 284

A Bartholin’s abscess will require antibiotics. A swab of pus or fluid from the abscess can be taken to culture the infective organism and check the antibiotic sensitivities. E. coli is the most common cause. Send specific swabs for chlamydia and gonorrhoea. Surgical interventions may be required to treat a Bartholin’s abscess. There are two options for surgical management: Word catheter (Bartholin’s gland balloon) – requires local anaesthetic Marsupialisation – requires general anaesthetic

Answer 285

Surgical management of a Bartholins abscess A Word catheter is a small rubber tube with a balloon on the end. The procedure may be performed by an appropriately experienced person in a treatment room, rather than a theatre. Local anaesthetic is used to numb the area. An incision is made, and any pus is drained from the abscess. The Word catheter is inserted into the abscess space, and inflated up to 3 ml with saline. The balloon fills the space and keeps the catheter in place. Fluid can drain around the catheter, preventing a cyst or abscess reoccurring. The tissue heals around the catheter, leaving a permanent hole. The catheter can be deflated and carefully removed at a later date, once epithelisation of the hole has occurred.

Answer 286

Surgical management of Bartholins abscess Marsupialisation involves a general anaesthetic in a surgical theatre. An incision is made, and the abscess is drained. The sides of the abscess are sutured open. Suturing the abscess open allows continuous drainage of the area and prevents recurrence of the cyst or abscess.

Answer 287

Lichen sclerosus is a chronic inflammatory skin condition that presents with patches of shiny, “porcelain-white” skin. It commonly affects the labia, perineum and perianal skin in women. It can affect other areas, such as the axilla and thighs. It can also affect men, typically on the foreskin and glans of the penis.

Answer 288

Lichen sclerosus is thought to be an autoimmune condition. It is associated with other autoimmune diseases, such as type 1 diabetes, alopecia, hypothyroid and vitiligo.

Answer 289

The diagnosis of lichen sclerosus is usually made clinically, based on the history and examination findings. Where there is doubt, a vulval biopsy can confirm the diagnosis.

Answer 290

The typical presentation in your exams is a woman aged 45 – 60 years complaining of vulval itching and skin changes in the vulva. The condition may be asymptomatic, or present with several symptoms: Itching Soreness and pain possibly worse at night Skin tightness Painful sex (superficial dyspareunia) Erosions Fissures The Koebner phenomenon refers to when the signs and symptoms are made worse by friction to the skin. This occurs with lichen sclerosus. It can be made worse by tight underwear that rubs the skin, urinary incontinence and scratching.

Answer 291

Changes affect the labia, perianal and perineal skin. There can be associated fissures, cracks, erosions or haemorrhages under the skin. The affected skin appears: “Porcelain-white” in colour Shiny Tight Thin Slightly raised There may be papules or plaques

Answer 292

Lichen sclerosis cannot be cured, but the symptoms can be effectively controlled. Lichen sclerosus is usually managed and followed up every 3 – 6 months by an experienced gynaecologist or dermatologist. Potent topical steroids are the mainstay of treatment. The typical choice is clobetasol propionate 0.05% (dermovate). Steroids are used long term to control the symptoms of the condition. They also seem to reduce the risk of malignancy. Steroids are initially used once a day for four weeks, then gradually reduced in frequency every four weeks to alternate days, then twice weekly. When the condition flares patients can go back to using topical steroids daily until they achieve good control. A 30g tube should last at least three months. Emollients should be used regularly, both with steroids initially and then as part of maintenance.

Answer 293

The critical complication to remember is a 5% risk of developing squamous cell carcinoma of the vulva. Other complications include: Pain and discomfort Sexual dysfunction Bleeding Narrowing of the vaginal or urethral openings

Answer 294

Bartholins abscess

Answer 295

The treatment for vaginal vault prolapse is sacrocolpoplexy

Answer 296

Nabothian cysts are fluid-filled cysts often seen on the surface of the cervix. They are also called nabothian follicles or mucinous retention cysts. They are usually up to 1cm in size, but rarely can be more extensive. They are harmless and unrelated to cervical cancer.

Answer 297

The columnar epithelium of the endocervix (the canal) produces cervical mucus. When the squamous epithelium of the ectocervix slightly covers the mucus-secreting columnar epithelium, the mucus becomes trapped and forms a cyst. This can happen after childbirth, minor trauma to the cervix or cervicitis secondary to infection.

Answer 298

Nabothian cysts are often found incidentally on a speculum examination. They do not typically cause any symptoms. Rarely, when they are very large, they may cause a feeling of fullness in the pelvis.

Answer 299

Nabothian cysts appear as smooth rounded bumps on the cervix, usually near to os (opening). They can range in size from 2mm to 30mm, and have a whitish or yellow appearance.

Answer 300

Nabothian cysts

Answer 301

Where the diagnosis is clear, women can be reassured, and no treatment is required. They do not cause any harm and often resolve spontaneously. If the diagnosis is uncertain, women can be referred for colposcopy to examine in detail. Occasionally they may be excised or biopsied to exclude other pathology. Rarely they may be treated during colposcopy to relieve symptoms.

Answer 302

There is no increased risk of coronary artery disease with oestrogen-only HRT (the risk may even be lower with HRT)

Answer 303

Undiagnosed abnormal bleeding Endometrial hyperplasia or cancer Breast cancer Uncontrolled hypertension Venous thromboembolism Liver disease Active angina or myocardial infarction Pregnancy

Answer 304

Take a full history to ensure there are no contraindications Take a family history to assess the risk of oestrogen dependent cancers (e.g. breast cancer) and VTE Check the body mass index (BMI) and blood pressure Ensure cervical and breast screening is up to date Encourage lifestyle changes that are likely to improve symptoms and reduce risks

Answer 305

Progestogens refer to any chemicals that target and stimulate progesterone receptors Progesterone is the hormone produced naturally in the body Progestins are synthetic progestogens

Answer 306

C19 progestogens are derived from testosterone, and are more “male” in their effects. Examples are norethisterone, levonorgestrel and desogestrel. These may be helpful for women with reduced libido. C21 progestogens are derived from progesterone, and are more “female” in their effects. Examples are progesterone, dydrogesterone and medroxyprogesterone. These may be helpful for women with side effects such as depressed mood or acne.

Answer 307

Oestrogen-only pills, for example, Elleste Solo or Premarin Oestrogen-only patches, for example, Evorel or Estradot

Answer 308

Cyclical combined tablets, for example, Elleste-Duet, Clinorette or Femoston Cyclical combined patches, for example, Evorel Sequi or FemSeven Sequi Mirena coil plus oestrogen-only pills, for example, Elleste Solo or Premarin Mirena coil plus oestrogen-only patches, for example, Evorel or Estradot

Answer 309

Continuous combined tablets, for example, Elleste-Duet Conti, Kliofem or Femoston Conti Continuous combined patches, for example, Evorel-Conti or FemSeven Conti Mirena coil plus oestrogen-only pills, for example, Elleste Solo or Premarin Mirena coil plus oestrogen-only patches, for example, Evorel or Estradot

Answer 310

Tibolone is a synthetic steroid that stimulates oestrogen and progesterone receptors. It also weakly stimulates androgen receptors. The effects on androgen receptors mean tibolone can be helpful for patients with reduced libido. Tibolone is used as a form of continuous combined HRT. Women need to be more than 12 months without a period (24 months if under 50 years). They would be expected not to have breakthrough bleeding. Tibolone can cause irregular bleeding, resulting in further investigations to exclude other causes.

Answer 311

Testosterone is a male sex hormone (androgen). It is naturally present in low levels in women. Menopause can be associated with reduced testosterone, resulting in low energy and reduced libido (sex drive). Treatment with testosterone is usually initiated and monitored by a specialist. It is given by transdermal application, applied as a gel or a cream to the skin.

Answer 312

Follow up three months after initiating HRT to review symptom and side effects Side effects often settle with time, so it is worth persisting for at least three months with each regime It takes 3 – 6 months of treatment to gain the full effects Problematic or irregular bleeding is an indication for referral to a specialist Ensure the woman has appropriate contraception Stop oestrogen-containing contraceptives or HRT 4 weeks before major surgery (NICE guidelines 2018 – NG89) Consider other causes of symptoms where they persist despite HRT (e.g. thyroid, liver disease and diabetes)

Answer 313

Nausea and bloating Breast swelling Breast tenderness Headaches Leg cramps

Answer 314

Mood swings Bloating Fluid retention Weight gain Acne and greasy skin

Answer 315

Where patients experience side effects, it is worth changing the type of HRT or the route of administration (switch between patches and pills). Patients with progestogenic side effects may do better switching to an HRT with a different form of progesterone. For example, patients with acne and mood swings may do better with a dydrogesterone progesterone (e.g. Femoston). In contrast, patients with reduced libido may do better with a norethisterone progesterone (e.g. Elleste-Duet). Progestogenic side effects can be avoided altogether by using a Mirena coil for endometrial protection. Unscheduled bleeding can occur in the first 3 – 6 months of HRT (in women with a uterus). If unscheduled bleeding continues, consider referral for investigations, particularly regarding endometrial cancer.

Answer 316

There is no specific regime for stopping HRT. It can be reduced gradually or stopped abruptly, depending on the preference of the woman. This choice does not affect long term symptoms. Gradually reducing the HRT may be preferable to reduce the risk of symptoms recurring suddenly.

Answer 317

multiple ovarian cysts, infertility, oligomenorrhea, hyperandrogenism insulin resistance

Answer 318

Absence of ovulation

Answer 319

Irregular infrequent ovulation

Answer 320

Absence of menstrual periods

Answer 321

Irregular, infrequent menstural periods

Answer 322

Hirsutism refers to the growth of thick dark hair, often in a male pattern, for example, male pattern facial hair Hyperandrogenism (pcos)

Answer 323

Oligomenorrhoea or amenorrhoea Infertility Obesity (in about 70% of patients with PCOS) Hirsutism Acne Hair loss in a male pattern

Answer 324

Insulin resistance and diabetes Acanthosis nigricans Cardiovascular disease Hypercholesterolaemia Endometrial hyperplasia and cancer Obstructive sleep apnoea Depression and anxiety Sexual problems

Answer 325

Acanthosis nigricans describes thickened, rough skin, typically found in the axilla and on the elbows. It has a velvety texture. It occurs with insulin resistance.

Answer 326

PCOS Medications, such as phenytoin, ciclosporin, corticosteroids, testosterone and anabolic steroids Ovarian or adrenal tumours that secrete androgens Cushing’s syndrome Congenital adrenal hyperplasia

Answer 327

Insulin resistance is a crucial part of PCOS. When someone is resistant to insulin, their pancreas has to produce more insulin to get a response from the cells of the body. Insulin promotes the release of androgens from the ovaries and adrenal glands. Therefore, higher levels of insulin result in higher levels of androgens (such as testosterone). Insulin also suppresses sex hormone-binding globulin (SHBG) production by the liver. SHBG normally binds to androgens and suppresses their function. Reduced SHBG further promotes hyperandrogenism in women with PCOS. The high insulin levels contribute to halting the development of the follicles in the ovaries, leading to anovulation and multiple partially developed follicles (seen as polycystic ovaries on the scan).

Answer 328

Testosterone Sex hormone-binding globulin Luteinizing hormone Follicle-stimulating hormone Prolactin (may be mildly elevated in PCOS) Thyroid-stimulating hormone

Answer 329

Raised luteinising hormone Raised LH to FSH ratio (high LH compared with FSH) Raised testosterone Raised insulin Normal or raised oestrogen levels

Answer 330

Pelvic ultrasound is required when suspecting PCOS. A transvaginal ultrasound is the gold standard for visualising the ovaries. The follicles may be arranged around the periphery of the ovary, giving a “string of pearls” appearance. The diagnostic criteria are either: 12 or more developing follicles in one ovary Ovarian volume of more than 10cm3

Answer 331

The screening test of choice for diabetes in patients with PCOS is a 2-hour 75g oral glucose tolerance test (OGTT). An OGTT is performed in the morning prior to having breakfast. It involves taking a baseline fasting plasma glucose, giving a 75g glucose drink and then measuring plasma glucose 2 hours later. It tests the ability of the body to cope with a carbohydrate meal. The results are: Impaired fasting glucose – fasting glucose of 6.1 – 6.9 mmol/l (before the glucose drink) Impaired glucose tolerance – plasma glucose at 2 hours of 7.8 – 11.1 mmol/l Diabetes – plasma glucose at 2 hours above 11.1 mmol/l

Answer 332

Weight loss Low glycaemic index, calorie-controlled diet Exercise Smoking cessation Antihypertensive medications where required Statins where indicated (QRISK >10%)

Answer 333

Endometrial hyperplasia and cancer Infertility Hirsutism Acne Obstructive sleep apnoea Depression and anxiety

Answer 334

Weight loss is a significant part of the management of PCOS. Weight loss alone can result in ovulation and restore fertility and regular menstruation, improve insulin resistance, reduce hirsutism and reduce the risks of associated conditions.

Answer 335

Orlistat may be used to help weight loss in women with a BMI above 30. Orlistat is a lipase inhibitor that stops the absorption of fat in the intestines

Answer 336

Obesity Diabetes Insulin resistance Amenorrhoea

Answer 337

Mirena coil for continuous endometrial protection Inducing a withdrawal bleed at least every 3 – 4 months with either: Cyclical progestogens (e.g. medroxyprogesterone acetate 10mg once a day for 14 days) Combined oral contraceptive pill

Answer 338

Under normal circumstances, the corpus luteum releases progesterone after ovulation. Women with PCOS do not ovulate (or ovulate infrequently), and therefore do not produce sufficient progesterone. They continue to produce oestrogen and do not experience regular menstruation. Consequently, the endometrial lining continues to proliferate under the influence of oestrogen, without regular shedding during menstruation. This is similar to giving unopposed oestrogen in women on hormone replacement therapy. It results in endometrial hyperplasia and a significant risk of endometrial cancer.

Answer 339

Women with extended gaps between periods (more than three months) or abnormal bleeding need to be investigated with a pelvic ultrasound to assess the endometrial thickness. Cyclical progestogens should be used to induce a period prior to the ultrasound scan. If the endometrial thickness is more than 10mm, they need to be referred for a biopsy to exclude endometrial hyperplasia or cancer.

Answer 340

Weight loss is the initial step for improving fertility. Losing weight can restore regular ovulation. A specialist may initiate other options where weight loss fails. These include: Clomifene Laparoscopic ovarian drilling In vitro fertilisation (IVF) Metformin and letrozole may also help restore ovulation under the guidance of a specialist; however, the evidence to support their use is not clear. Ovarian drilling involves laparoscopic surgery. The surgeon punctures multiple holes in the ovaries using diathermy or laser therapy. This can improve the woman’s hormonal profile and result in regular ovulation and fertility.

Answer 341

Women that become pregnant require screening for gestational diabetes. Screening involves an oral glucose tolerance test, performed before pregnancy and at 24 – 28 weeks gestation.

Answer 342

Weight loss may improve the symptoms of hirsutism. Women are likely to have already explored options for hair removal, such as waxing, shaving and plucking. Co-cyprindiol (Dianette) is a combined oral contraceptive pill licensed for the treatment of hirsutism and acne. It has an anti-androgenic effect, works as a contraceptive and will also regulate periods. The downside is a significantly increased risk of venous thromboembolism. For this reason, co-cyprindiol is usually stopped after three months of use. Topical eflornithine can be used to treat facial hirsutism. It usually takes 6 – 8 weeks to see a significant improvement. The hirsutism will return within two months of stopping eflornithine. Other options that may be considered by a specialist experienced in treating hirsutism include: Electrolysis Laser hair removal Spironolactone (mineralocorticoid antagonist with anti-androgen effects) Finasteride (5α-reductase inhibitor that decreases testosterone production) Flutamide (non-steroidal anti-androgen) Cyproterone acetate (anti-androgen and progestin)

Answer 343

Topical eflornithine can be used to treat facial hirsutism. It usually takes 6 – 8 weeks to see a significant improvement. The hirsutism will return within two months of stopping eflornithine.

Answer 344

Co-cyprindiol (Dianette) is a combined oral contraceptive pill licensed for the treatment of hirsutism and acne. It has an anti-androgenic effect, works as a contraceptive and will also regulate periods. The downside is a significantly increased risk of venous thromboembolism. For this reason, co-cyprindiol is usually stopped after three months of use.

Answer 345

Asherman’s syndrome is where adhesions (sometimes called synechiae) form within the uterus, following damage to the uterus. Usually Asherman’s syndrome occurs after a pregnancy-related dilatation and curettage procedure, for example in the treatment of retained products of conception (removing placental tissue left behind after birth). It can also occur after uterine surgery (e.g. myomectomy) or several pelvic infection (e.g. endometritis).

Answer 346

Endometrial curettage (scraping) can damage the basal layer of the endometrium. This damaged tissue may heal abnormally, creating scar tissue (adhesions) connecting areas of the uterus that are generally not connected. There may be adhesions binding the uterine walls together, or within the endocervix, sealing it shut. These adhesions form physical obstructions and distort the pelvic organs, resulting in menstruation abnormalities, infertility and recurrent miscarriages. Adhesions may be found incidentally during hysteroscopy. Asymptomatic adhesions are not classified as Asherman’s syndrome.

Answer 347

Asherman’s syndrome typically presents following recent dilatation and curettage, uterine surgery or endometritis with: Secondary amenorrhoea (absent periods) Significantly lighter periods Dysmenorrhoea (painful periods) It may also present with infertility.

Answer 348

Hysteroscopy is the gold standard investigation, and can involve dissection and treatment of the adhesions Hysterosalpingography, where contrast is injected into the uterus and imaged with xrays Sonohysterography, where the uterus is filled with fluid and a pelvic ultrasound is performed MRI scan

Answer 349

Management is by dissecting the adhesions during hysteroscopy. Reoccurrence of the adhesions after treatment is common.

Answer 350

A bicornuate uterus is where there are two “horns” to the uterus, giving the uterus a heart-shaped appearance. It can be diagnosed on a pelvic ultrasound scan. A bicornuate uterus may be associated with adverse pregnancy outcomes. However, successful pregnancies are generally expected. In most cases, no specific management is required. Typical complications include: Miscarriage Premature birth Malpresentation

Answer 351

Imperforate hymen is where the hymen at the entrance of the vagina is fully formed, without an opening. Imperforate hymen may be discovered when the girl starts to menstruate, and the menses are sealed in the vagina. This causes cyclical pelvic pain and cramping that would ordinarily be associated with menstruation, but without any vaginal bleeding.

Answer 352

An imperforate hymen can be diagnosed during a clinical examination. Treatment is with surgical incision to create an opening in the hymen.

Answer 353

Theoretically, if an imperforate hymen is not treated retrograde menstruation could occur leading to endometriosis.

Answer 354

Transverse vaginal septae is caused by an error in development, where a septum (wall) forms transversely across the vagina. This septum can either be perforate (with a hole) or imperforate (completely sealed). Where it is perforate, girls will still menstruate, but can have difficulty with intercourse or tampon use. Where it is imperforate, it will present similarly to an imperforate hymen with cyclical pelvic symptoms without menstruation. Vaginal septae can lead to infertility and pregnancy-related complications.

Answer 355

Diagnosis is by examination, ultrasound or MRI. Treatment is with surgical correction. The main complications of surgery are vaginal stenosis and recurrence of the septae.

Answer 356

Vaginal hypoplasia refers to an abnormally small vagina. Vaginal agenesis refers to an absent vagina. These occur due to failure of the Mullerian ducts to properly develop, and may be associated with an absent uterus and cervix. The ovaries are usually unaffected, leading to normal female sex hormones. The exception to this is with androgen insensitivity syndrome, where there are testes rather than ovaries. Management may involve the use of a vaginal dilator over a prolonged period to create an adequate vaginal size. Alternatively, vaginal surgery may be necessary.

Answer 357

Androgen insensitivity syndrome is a condition where cells are unable to respond to androgen hormones due to a lack of androgen receptors. It is an X-linked recessive genetic condition, caused by a mutation in the androgen receptor gene on the X chromosome. Extra androgens are converted into oestrogen, resulting in female secondary sexual characteristics. It was previously known as testicular feminisation syndrome.

Answer 358

It is an X-linked recessive genetic condition, caused by a mutation in the androgen receptor gene on the X chromosome. Patients with androgen insensitivity syndrome are genetically male, with XY sex chromosome. However, the absent response to testosterone and the conversion of additional androgens to oestrogen result in a female phenotype externally. Typical male sexual characteristics do not develop, and patients have normal female external genitalia and breast tissue.

Answer 359

Typical male sexual characteristics do not develop, and patients have normal female external genitalia and breast tissue. (Absent response to testosterone causing conversion to oestrogen) Patients have testes in the abdomen or inguinal canal, and absence of a uterus, upper vagina, cervix, fallopian tubes and ovaries. The female internal organs do not develop because the testes produce anti-Müllerian hormone, which prevents males from developing an upper vagina, uterus, cervix and fallopian tubes.

Answer 360

Androgen insensitivity syndrome often presents in infancy with inguinal hernias containing testes. Alternatively, it presents at puberty with primary amenorrhoea. Female external characteristics such as breasts and appearance of female genitalia The insensitivity to androgens also results in a lack of pubic hair, facial hair and male type muscle development. Patients tend to be slightly taller than the female average.

Answer 361

Raised LH Normal or raised FSH Normal or raised testosterone levels (for a male) Raised oestrogen levels (for a male)

Answer 362

micropenis or clitoromegaly, bifid scrotum, hypospadias and diminished male characteristics.

Answer 363

Patients are infertile, and there is an increased risk of testicular cancer unless the testes are removed. Inguinal hernia Ammenrohea

Answer 364

Management is coordinated by a specialist MDT, involving paediatrics, gynaecology, urology, endocrinology and clinical psychology. Medical input involves: Bilateral orchidectomy (removal of the testes) to avoid testicular tumours Oestrogen therapy Vaginal dilators or vaginal surgery can be used to create an adequate vaginal length Generally, patients are raised as female, but this is sensitive and tailored to the individual. They are offered support and counselling to help them understand the condition and promote their psychological, social and sexual wellbeing.

Answer 365

Smoking cessation Small meals regularly Complex Carbohydrate rich foods Exercise Alchol reduction Regular sleep Sleep reduction

Answer 366

Dermoid cysts, due to their size and density (secondary to mucin, teeth etc..), are most likely to tort. They will normally have a long pedicle because of their weight and as a result will twist (normally anti-clockwise).

Answer 367

f) A high vaginal swab for nucleic acid amplification test (NAAT) is vital. This is to test for gonorrhoea and chlamydia. A high vaginal Amies swab for bacterial and fungal culture should be performed, as well as an endocervical culture for gonorrhoea (due to increasing rates of resistance to first line cephalosporin therapies).

Answer 368

Area of white, Ill definied

Answer 369

Marsupialisation of the acute Bartholin’s abscess combines the drainage required to treat the abscess, as well as maintaining the gland drainage and reducing risk of recurrence. It would be appropriate to start antibiotics if the patient was systemically unwell.

Answer 370

Powder burn spots affecting the pelvic peritoneum

Answer 371

Overflow A high voiding detrusor pressure with a low peak flow rate is indicative of bladder outlet obstruction

Answer 372

Pelvic fluid is a common but non-specific finding that represents transudate from the ovarian capsule due to venous and lymphatic obstruction

Answer 373

Uterine fibroids are sensitive to oestrogen and can therefore grow during pregnancy. If growth outstrips their blood supply, they can undergo red or 'carneous' degeneration. This usually presents with low-grade fever, pain and vomiting. The condition is usually managed conservatively with rest and analgesia and should resolve within 4-7 days.

Answer 374

Enterocoele Vaginal vault prolapse